HomeMy WebLinkAbout0022 ACORN DRIVE - Health i
22 Acorn Drive
- Osterville
A= 120 - 025 I
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,I
Commonwealth of Massachusetts
W Title 5 Official Inspecth:�n Form
Subsurface Sewage Disposal System Form -Not for /oluntary Assessments
22 Acorn Drive
Property Address i
Bob Hallett i.
Owner Owner's Name i
information is •.
required for every Osterville MA i 02655. ., 4/23/14
page. City/Town State { Zip Code Date of Inspection
Inspection results must be submitted on this form; Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
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Important:When f t
filling out forms A. General Information _..
.on the computer,
use only the tab 1. Inspector: I
key to move your V
I 5
cursor-do not James Ford
key the return Name of Inspector .
Y
rab Company Name
P.O. Box 49
Company Address
rewn Osterville MA 02655
City/Town ,State Zip Code
508-862-9400 iS12482
Telephone Number ,License Number
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B. Certification
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certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complex as of the time of the inspection.The inspection
was performed based on my training and experience in sine proper function and maintenance of on site
sewage disposal systems. I am a DEP approved syster'i inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000). The system: +
® Passes ❑ Conditionally'Passes ❑ Fails
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❑ Needs Further v luation by the Local Approving Authority
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_4/28/14
Inspec 's Signature )ate
The ys em inspector shall submit a copy of this inspection report to the Approving Authority(Board
of He or DEP)within 30 days of completing this,ir�.Spection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DER'The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the,approving authority.
****This report only describes :;onditions at the time of inspection and under the conditions of use
at that time.This inspectia.i does not address Foav the system will perform in the future under
the same or different conditions of use.
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t5ins•3/13 Titled,Official InspffFr ubsurface Sewage Disposal System•Page 1 of 17
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Commonwealth of Massachusetts
P
w Title 5 Officials; lnspection Fora
Subsurface Sewage Disposal :system Form- Not for Voluntary Assessments
°M 22 Acorn Drive
Property Address
Bob Hallett _
Owner Owner's Name j
information is
required for every Osterville MA'' 02655 4/23/14
page. City/Town State' Zip Code Date of inspection-
B.
Certification (cont.) fi
:I
Inspection Summary: Check A,B,C,D or E/a/ways!?complete all of Section D
A) System Passes: I
® I have not found any infcrmation which indicates;that any of the failure criteria described
in 310 CMR 15.303 or in-;310 CMR 15.304 exist.'Any failure criteria not evaluated are
indicated below. r
Comments: {
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B) System Conditionally Passes: '
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El one or more system components as described in the"Conditional Pass"section need to be
replaced or repaired. The system, upon completl�n of the replacement or repair, as approved by
the Board of Health, will.pass.
Check the box for"yes", "no;or"not determined"(Y; iV, ND)for the following statements. If"not
determined," please explain.',
The septic tank is metal and'over 20 years old*or the septic tank(whether metal or not) is structurally
unsound, exhibits substantiai infiltration or exfiltration`or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health. ,
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20'yqIars old is available.
❑ Y ❑ N ❑ ND (Explain below):;,
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l� Title j Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 B
n 1 P
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Commonwealth of Massachusetts
_ Title 5 Offi cial In specti�n Form ,
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M 22 Acorn Drive
Property Address
4i• � Il
Bob Hallett
Owner Owner's Name
information is
required for every Osterville MA ;t 02655 4/23/14
page. Cltyrrown
State:, 1 Zip Code Date of Inspection
B. Certification (cont.)
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❑ Pump.Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired. ;
B) System Conditionally Passes (cont.): a'i
❑ Observation of sewage backup or break out or High static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are,replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed 11.❑ Y ❑ N ❑ ND (Explain below):
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❑ distribution box is leveled or replaced '❑ Y ❑ N ❑ ND(Explain below):
❑ The system required pumping more than 4 tim'ea�l a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)aire„replaced JEJ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed
` ;❑ Y ❑ N ❑ ND (Explain below):
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C) Further Evaluation is Required by the Board,,�f Health:
❑ Conditions exist which require further evaluation Eby the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health'd6termines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
o
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bWMering vegetated wetland or a salt marsh
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Title-5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
i
Commonwealth of Massachusetts
Title 5 Official- Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M ,• 22 Acorn Drive ,
Property Address
Bob Hallett l'
Owner Owner's Name
information is
required for every Osterville MA 02655 4/23/14
page. City/Town -S-ta-tel Zip Code Date of Inspection
B. Certification (cont.)
2. System will fall unlel'ss the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in manner that protects the public health,
safety and environment-.
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributaryito,ia surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well. r I
❑ The system has a.septic'tank and SAS and the SAS is less than 100 feet but 50 fe
et or
more from a private water supply well".
Method used to determi6e distance: ;
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence.bf ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must
be attached to this form.
3. Other:
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D) System Failure Criteria Applicable to All Systems
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You must indicate"Yes" or"No"to each of the!fc llowing for all inspections:
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Yes No ;4
❑ ® Backup of sewage into facilitycT system component due to overloaded or
clogged SAS or cesspool i
❑ _ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool '
❑ Liquid:depth in.cesspool is less"than 6" below invert or available volume is less
than Y9 day flow
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Title S Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
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Commonwealth of Massachusetts
u Title 5 Official: Inspecti®n Fora
Subsurface Sewage Disposal System Form -Not fdr,Voluntary Assessments
22 Acorn Drive
Property Address I
Bob Hallett 'j
Owner Owner's Name
information is
required for every Osterville MA 02655 4/23/14
page. Citylrown State� Zip Code Date of Inspection
B. Certification (cont.)
Yes No
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❑ ® Required,pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of,,times pumped: .
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or' ri is within a Zone 1 p, Y of a public well.
❑ ® Any peirtion of a cesspool or'prjvy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or;pr4vy is less than 100 feet but greater than 50 feet
from a',private water supply Weil with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform1bacteria indicates absent and the presence
of ammonia nitrogen and filtrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails.-1 have deter'bined that one or more of the above failure
criteriaexist as described in 31,0 CIVIR 15.303, therefore the system fails. The
system owner should contact tthe.Board of Health to determine what will be
necessaryto correct the failurei
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd. i
For large systems, you must'indicate either"yes"or';no"to each of the following, in addition to the
questions in Section D.
Yes No e
❑ ❑ the system is within 400 feet of?a surface drinking water supply
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❑ ❑ the system is within 200 feet of°a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area— IWPA)or a mapped Zone II of a public water supply well
If you have answered "yes"to any question in Section E the system is considered a significant threat,
or answered "yes" in Section,D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section!� or failed under Section D shall upgrade the
system in accordance with 310,CMR 15.304.The sy em owner should contact the appropriate
,regional office of the Department.
l5ins•3/13
Title.5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17
a
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Commonwealth of Massachusetts
W Title 5 Official Inspection Forin
Subsurface Sewage Disposal System Form- Not for'�oluntary As essments
°M 22 Acorn Drive
Property Address
Bob Hallett
Owner Owner's Name g
information is
required for every Osterville MA 02655 4/23/14
page. City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must'in,
icate"'yes" o "no•" as to each of the following:
Yes No
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® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
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® ❑ Has thelsystem received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the systeii obtained ar d examined?(If they were not
available note as N/A) 0.
❑ ® Was the facility or dwelling inspected for signs of sewage back up?
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® ❑ Was the site inspected for signslof break out.
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® ❑ Were all system components,,excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, o ened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
El ® Was the facility owner(and occupants if differ nt from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the fSoil Absorptio ri System (SAS)on the site has
been determined based on:
® ❑ Existinginformation. For exampIp, a plan at the Board of Health.
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® ❑ Determined in the field (if any of.;fhe failure cri eria related to Part C is at issue
approximation of distance is unacceptable) [3 0 CMR 15.302(5)]
D. System Information
Residential Flow Conditions
Number of bedrooms (design):, - Number of bedrooms (actual): 4
. .
DESIGN flow based on 310 tMR 15.203 (for exam,pl'�: 110 gpd x of bedrooms): 44-
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Title Official Inspection Fo m:Subsurface Sewage Disposal System•Page 6 of 17
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Commonwealth of Massachusetts ` ;{
W Title 5 Official; lnspectiOn Form
Subsurface Sewage Disposal �ystem Form -Not for Voluntary Assessments
°.W 22 Acorn Drive
Property Address
Bob Hallett -
Owner Owner's Name
information is I
required for every Osterville MA 1 02655 4/23/14
page. Citylrown 4 State 4, Zip Code Date of Inspection
D. System Informatio6
Description:
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Number of current residents 2
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system?(Include laundry system inspection
information in this report.) 3 ❑ Yes ® No
Laundry system inspected?
i ❑ Yes ® No
Seasonal use?
i;, ❑ Yes ® No
Water meter readings, if available (last 2 years usage(gpd)):
Detail: '
unavailable
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Sump pump?
❑ Yes ® No
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Last date of occupancy:
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
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Design flow(based on 310 CMR 15.203): i
Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.): t
Grease trap present? I
❑ Yes ❑ No
Industrial waste holding tank;'present?
,t El Yes ❑ No
Non-sanitary waste discharged to the Title 5 system?�
❑ Yes ❑ No
Water meter readings, if available:
t5ins-3/13
T111e.54Official Inspection Form:Subsurface Sewage Disposal System Page 7 of 17
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Commonwealth of Massachusetts
Title 5 Official lnspecti 'n Form
Subsurface Sewage Disposal System Form -Not for:.Voluntary Assessments
M 22 Acorn Drive i
Property Address
Bob Hallett
Owner Owner's Name
information is
required for every
OSterVllle MA
02655 4/23/14
page. City/Town State' s Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use:,
Date
Other(describe below):
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General Information
Pumping Records:
C r.
Source of information: unavailable
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Was system pumped as part of the inspection? ;f ® Yes No
If yes, volume pumped: 1590:
gallons
How was quantity pumped detpl-mined?
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Reason for pumping: maintenance
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cessl)*061
❑ Overflow cesspool '
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/alternative technology.'Attach a copy of the current operation and
maintenancra contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. A4tach a copy of the DEP;approval.
❑ Other(describe):
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t5ins•3/13 Title�Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
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Commonwealth of Massq'r-husetts
Title 5 Official; Inspection Form
Subsurface Sewage Disposal System Form -Not for,Voluntary Assessments
,M 22 Acorn Drive
Property Address
Bob Hallet
t
Owner
Owner's Name G.
information is
required for every Osterville MA ' 'I 02655 4/23/14
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed(i�known)and source of information:
installed on 7/27/07-per as�byilt ;I
Were sewage odors detected.when arriving at the's te?
❑ Yes [E No
BuildingSewer locate on ,Ite plan):
( � p )
Depth below grade: `
feet
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Material of construction:
❑ cast iron ® 40 Pvt
❑ other(explain);' a
Distance from private water supply well or suction line.
t feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
)
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Septic Tank(locate on site Plan):
Depth below grade: 2 ' •
r feet
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Material of construction:
® concrete ❑ motal ❑fiberglass polyethylene
❑ other(explain)
If tank is metal,list age:
years
Is age confirmed by a Certifi6.ate of Compliance? (attach a copy of certificate) ❑ Yes El No
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Dimensions: 1500 gals.
Sludge depth: 21'
t5ins•3/13
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
-
Commonwealth of Massachusetts
Title 5 Officia1 Inspection Form
Subsurface Sewage Disposal system Form-Not for'Voluntary Assessments
�M •'`f 22 Acorn Drive
Property Address
Bob Hallett
Owner Owner's Name
information is
required for every Osterville _ MA 1 02655 4/23/14
page. City/Town State i Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.) 1
Distance from top of sludge io bottom of outlet tee or baffle
29"
Scum thickness
4"
Distance from top of scum to top of outlet tee or baffle
6"
Distance from bottom of scum to bottom of outlet tee or baffle
12"
How were dimensions deterrpined? measure
Comments (on pumping recommendations,inlet and[outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of,leakage, etc.):
The tees were present. The liquid was even with the'outlet. The tank was pumped after the
insepection.The inlet cover was 12"below grade.'
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Grease Trap(locate on site oIbn):' '
Depth below grade: i
fi feet
Material of construction:
1
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene
❑ other(explain):
N/a
Dimensions: 3
Ig
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Scum thickness pr
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or.baffle
Date of last pumping:
Date
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Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
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Commonwealth of Massachusetts i
W Title 5 Official Inspection Form
Subsurface Sewage Disposal :bystem Form Not for;Voluntary Assessments
22 Acorn Drive
4
Property Address
Bob Hallett
Owner Owner's Name i
information is i'
required for every Osterville MA ;1 02655 4/23/14
page. City/Town State Zip Code Date of Inspection
D. System Inf
ormation (,c ont.)
Comments (on pumping rectlmmendations, inlet ancr outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tangy;must be pumped at rime of inspection) (locate on site plan):
Depth below grade: 1 i
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene
❑ other(explain):
N/a
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Dimensions:
Capacity:
'gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: 7` 'Alarm in working order: ❑ Yes ❑ No
Date of last pumping: I '
f Date
Comments (condition of alarm and float switches, eta.):
I '
Attach copy of current pumping contract(required). I ,copy attached?
❑ Yes ❑ No
t5ins-3/13 •
Title-5 official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
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I
Commonwealth of Massachusetts
j Title 5 Official inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 22 Acorn Drive
Property Address
Bob Hallett ,
Owner Owner's Name
information is 4
required for every Osterville MA ? 02655 4/23/14
page. City/Town State ,� Zip Code Date of Inspection
D. System Information (cont.) �"
Distribution Box(if present,must be opened)(locate on site plan):
Depth of liquid level above outlet invert # even
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of.leakage,into or out of box, etc.):
The D-box was normal:
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Pump Chamber(locate on site plan):
'
Pumps in working order: El Yes ❑ No*
Alarms in working order::
❑ Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
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* If pumps or alarms are not;n working order, systerMs a conditional pass.
Soil Absorption System (SAS) (locate on site plan, pzcavation not required):
If SAS notlocated, explain why:
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Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17,
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�t
M 22 Acorn Drive
Property Address
Bob Hallett
Owner Owner's Name -
information is r
required for every Osterville MA ;_+ 02655 4/23/14
page. City/Town State' Zip Code Date of Inspection
D. System Information (cont.)
i
Type:
❑ leaching pits number:
® leaching chambers number:. 5- infiltrators
1 Vx 42'
❑ leaching gal Ie.ries number:
❑ leaching trenches . number,length:
❑ leaching field's, number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
The galleys were clean.There was no signs of failure A camera was used for the inspection
4
Cesspools (cesspool must be pumped as part of inspection)(locate on site plan):
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Number and configuration ;t N/a
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Depth—top of liquid to inlet 'nvert
Depth of solids layer
is
Depth of scum layer
Dimensions of cesspool
Materials of construction `
Indication of groundwater inflow ❑ Yes ❑ No
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Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
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1
Commonwealth of Massachusetts i
Title 5 Official;: Inspection Form
Subsurface Sewage Disposal System Form -Not for'Voluntary Assessments
,M 22 Acorn Drive -
Property Address
Bob Hallett i
Owner Owner's Name
information is g
required for every Osterville MA 02655 4/23/14
page. City/Town State Zip Code Date of Inspection
D. System Information' (cont.)
Comments (note condition of soil, signs of hydrauiic'failure, level of'ponding, condition of vegetation,
etc.):
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Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of.ponding, condition of vegetation,
etc.):
N/a
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Title 5:official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17
t .
Commonwealth of Massathusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not forVoluntary Assessments
22 Acorn Drive
Property Address
Bob Hallett
Owner Owner's Name
information is
required for every Osterville MA . 02655 4/23/14
page. Cityrrown StateP Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal"System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
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Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
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' Commonwealth of Massachusetts ,4
Title 5 Official` Inspecti' ' n Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,M 22 Acorn Drive ),
Property Address
Bob Hallett
Owner Owner's Name i
information is
required for every Osterville MA !I 02655 4/23/14
page. City/Town Sta Zip Code Date of Inspection
D. System Information (cont.)
Site Exam: i
❑ Check Slope
❑ Surface water .;
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: 30' +/-
feet
Please indicate all methods used to determine the l igh ground water elevation:
❑ Obtained from system design plans on record
If checked, date of,design plan reviewed:
Date
❑ ' Observed site(abuttin
g g property/observation hole within 150 feet of SAS)
® Checked with local Board of Health -explain:
Using topo and"water contours maps :.:j
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❑ Checked with local excavators, installer;-(attach documentation)
❑ Accessed USGS database-explain: s
You must describe how you established.the high ground water elevation:
see above
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Before filing this Inspection Report, please see;Report Completeness Checklist on next page.
t5ins-3/13
Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17
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Commonwealth of Massachusetts
Title 5 Official' Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
W.N
22 Acorn Drive
Property Address
Bob Hallett
Owner Owner's Name
information is r
required for every Osterville MA 02655 4/23/14
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary:A, B, C, D, or E checked ;
® Inspection Summary D (System Failure Criteria i Applicable to All Systems)completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Dispt,Sol System either drawn on page 15 or attached in separate file
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t5ins-3/13
Title 5+Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17,
f
Commonwealth of Massachusetts )
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
'< 22 Acorn Drive
Property Address
One West Bank
Owner Owner's Name
information is required for Osterville MA 02655 04/15/2010
every page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out A. General Information
forms on the 1
computer,use 1. Inspector: ( �.
only the tab key
to move your A.Riker
cursor-do not Name of Inspector
use the return
key. R.L.C.
Company Name
P.O. Box 726
Company Address
South Yarmouh MA 02664
Cityrrown State Zip Code
508-776-6460 S14590
Telephone Number License Number „a �
CD
B. Certification K
I certify that I have personally inspected the sewage disposal system at this address and thatthe ,
information reported below is true, accurate and complete as of the time of the inspection. Thb ins`-fiction
was performed based on my training and experience in the proper function and m intenanoeabf or�gite
sewage disposal systems. I am a DEP approved system inspector pursuant to$ection t15.340�a�
Title 5(310 CMR 15.000).The system: °
0 Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
04/17/2010
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
,of Health.or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
""This report'only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
,I
t5ins•09/08 Title 5 Official Inspection Fonn:Subsu4Sewagosal System•Page 1 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
22 Acorn Drive
Property Address
One West Bank
Owner Owner's Name
information is required for Osterville MA 02655 04/15/2010
every page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary:.Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
Complete System replacement in 07/27/2007 with 1500 gallon precast septic tank ,distribution box
with 5 x 3050 Infiltrators with 2'effective depth with 3' stone on sides and 3.5' stone on ends.On
inspection of system there no failures observed. Town of Barnstable had engineered plans on file
with certificate of compliance.
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass"section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is
structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System
will pass inspection if the existing tank is replaced with a complying septic tank as approved by the
Board of Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ N®(Explain below):
t5ins•09/08 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
22 Acorn Drive
Property Address
One West Bank
Owner Owner's Name
information is required for Osterville MA 02655 04/16/2010
every page. City/Town State Zip.Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
m�
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M '~ 22 Acorn Drive
Property Address
One West Bank
Owner Owners Name
information is Osterville MA 02655 04/15/2010
required for _
every page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS.is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform
bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be
attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes"or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
El ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less.than 6" below invert or available volume is less
than '/z day flow
t5ins-09108 Tide 5 Official Inspection Form;Subsurface Sewage Disposal System-Page 4 of 17
I ,
Commonwealth of Massachusetts
ugTitle 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
22 Acorn Drive
Property Address
One West Bank
Owner Owner's Name
information is required for Osterville MA 02655 04/15/2010
every page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ E Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails.The
system owner should contact the Board of Health-to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA)or a mapped Zone 11 of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,
or answered"yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
22 Acorn Drive
Property Address
One West Bank
Owner Owner's Name
information is required for Osterville MA 02655 04/15/2010
every page. City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes" or"no" as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
❑ ® Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined?(If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ® Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) (310 CMR 15.302(5)1
D. System Information
Residential Flow Conditions:
Number of bedrooms(design): four Number of bedrooms(actual): four
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 Gpd
tSins•09/08 Title 5 Official Inspection Form:Subsurtace Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
up
Tietle 5 ®fficial Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
22 Acorn Drive
Property Address
One West Bank
Owner Owners Name
information is required for Osterville MA 02655 04/15/2010
every page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
Property was vacant at time of inspection . Water records were recorded for previous periods. On
observation of all components there was no evidence of back up or high effluent levels observed.
Number of current residents: unk.
Does residence have a garbage grinder? ❑ Yes ® No 1
Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No
I
Laundry system inspected? ® Yes ❑ No
Seasonal use? ® Yes ❑ No
Water meter readings, if available last 2 ears usage 2009=49.32 gpd j
9 ( Y 9 (gpd)): 2008=16.44 gpd
Detail:
Water record show system received flow under design specifications.
I
Sump pump? ❑ Yes ® No
Last date of occupancy: unk.
Date
Commercial/industrial Flow Conditions:
Type of Establishment:
i
Design flow(based on 310 CMR 15.203): gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
22 Acorn Drive
Property Address
One West Bank
Owner Owner's Name
information is required for Osterville MA 02655 04/15/2010
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information: Barnstable
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
not required
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology.Attach a copy of the current operation and
maintenance contract(to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
22 Acorn Drive
Property Address
One West Bank
Owner Owner's Name
information is required for Osterville MA 02655 04/15/2010
every page. City/Town state Zip Code Date of Inspection
D. System Information (cunt.)
Approximate age of all components, date installed-(if known)and source of information:
All componenets new.in 2007
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate'on site plan):
Depth below grade: feet
Material of construction:
®cast iron ❑40 PVC copper to cast iron
other(explain):
Distance from private water supply well or suction line: 12
fleet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Copper to cast iron interior plumbing dry and tight.
Septic Tank(locate on site plan):
Depth below grade: 1
.feet
Material of construction:
® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain)
1500 gallon precast concrete tank
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance?.(attach a copy of certificate) ❑ Yes ❑ No
5'8" Hx10'6"Lx5.8"W
Dimensions:
10"
Sludge depth:
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
w 22 Acorn Drive
Property Address
One West Bank
Owner Owner's Name
information is required for Osterville MA 02655 04/15/2010
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
24"
Scum thickness no scum
Distance from top of scum to top of outlet tee or baffle n/a
Distance from bottom of scum to bottom of outlet tee or baffle n/a
How were dimensions determined? Sludge Judge
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tank had very little soilds . Pipes were at correct inverts and tank had no obvious structural defects.
Grease Trap(locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
f
Commonwealth of Massachusetts -
W Title 5 Official Inspection Four'
Subsurface Sewage Disposal System Forms Not for Voluntary Assessments
22 Acorn Drive
Property Address
One West Bank
Owner Owner's Name
information is required for Osterville MA 02655 04/15/2010
every page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑concrete ❑ metal ❑fiberglass El polyethylene ❑other(explain):
Dimensions:
Capacity:
gallons
Design Flow:
gallons.per day .
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments(condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
r 22 Acorn Drive
Property Address
One West Bank
Owner Owner's Name
information is required for Osterville MA 02655 04/15/2010
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (coot.)
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert at invert
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
No evidence of carry over or high water staining in distribution box.Box was level and had no
indication of leakage.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins•09108 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
22 Acorn Drive
Property Address
One West Bank
Owner Owner's Name
information is required for Osterville MA 02655 04/15/2010
every page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits., number:
® leaching chambers number: 5x 3050
Infiltrators
❑ leaching galleries number:
ti
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
All soils above S.A.S. free of effluent staining or septic odors.No increase vegitation or damp soils
observed.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool —
Materials of construction —
Indication of groundwater inflow ❑ Yes ❑ No
t5ins-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
y< 22 Acorn Drive
Property Address
One West Bank
Owner Owner's Name
information is required for Osterville MA 02655 04/15/2010
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
y� 22 Acorn Drive
Property Address
One West Bank
Owner Owner's Name,
information is required for Osterville MA 02655 04115I2010
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
® hand-sketch in the area below
drawing attached separately
A= E'iO Neck coddler A - � 1717to
= p j1A ftrc^4 CHedi$r A _ a a g
jar B� - 1W Jr
0
I6aL,sl
ell � g- 3 " ►�
4r g- 55.
S C-3"t S Y
g e , $l y1
A o C_
C 33'
-�'
� � y
VS
I
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
22 Acorn Drive
Property Address
One West Bank
Owner Owner's Name
information is required for Osterville MA 02655 04/15/2010
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
Z Check cellar
® Shallow wells
Estimated depth to high ground water: no ground water at 132"feet
Please indicate all methods used to determine the high ground water elevation:
® Obtained from system design plans on record
If checked, date of design plan reviewed: 02/12/2007
Date
El Observed site(abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health -explain:
Plan and test hole data on file 1/18/2007
❑ Checked with local excavators, installers (attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Plan on file with current test hole data from 1/18/2007
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins-09/08 Ttle 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
22 Acorn Drive
Property Address
One West Bank
Owner Owner's Name
information is Osterville MA 02655 04/15/2010
required for
every page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
TOWIST OF BARNSTABLE N
LOCATION �.Z �eo�n �E�.,, SEWAGE # 7—�
VILLAGE 626MI'1I.2 ASSESSOR'S MAP & LOT
ZI
INSTALLER'S NAME&PHONE NO.(Ooao iiz/k 2A L VQ
SEPTIC TANK CAPACITY S00 Afi O
LEACHING FACIL=: (type) ��'�Ai' (size) �(Q
NO. OF BEDROOMS__
BUILDER OR OWNER o
PERMITDATE: a I�'� COMPLIANCE DATE: 7
Separation Distance Between the:
Maximum Adjusted'Groundwater Table to the Bottom of Leaching Facility N� Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland'and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
�y
f� .
-
3 5110
ri
r31 31, 3 .
-7, 7
LJONo. Fee
,THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
3pplicatiou for Mtgozal 6pztem Couotrurttou Permit
Application for a Permit to Construct( ) Repair Upgrade( Abandon( Complete System ❑Individual Components
Location Address or Lot No. Z Z ACou-) Owner's Name,Address,and Tel.No.
Assessor's Map/Parcel I Zc)Installer's Name,Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
CAPE Wtc�£ ENS, LLC
42$-4o2�8 Q
Type of Building:
Dwelling No.of Bedrooms Lot Size ?_0 sq.ft. Garbage Grinder ( �)J
Other Type of Building N No.of Persons Showers( k/ 'Cafeteria( t�
Other Fixtures Ln, C,, kt C'►)RL\_ _ t� Lau t-6Cu
Design Flow(min.required) �� gpd Design flow provided ���p r S40 gpd
Plan Date 2.'S ' C7 Number of sheets I Revision Date r"
TitleS'L�GkfyN
Size of Septic Tank ��; o � ) O�i Type of S.A.S. 6. 3b SCrS —_TIZEVN C
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) QC
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Boar Health.
Sign Date Z ( Z Z(zo7
Application Approved by eu, Date a ^( a 7
Application Disapproved by: Date
for the following reasons
Permit No. -7— 0 w Date Issued 2�� -7
No. .2oo-7 OV ' °' - �?'d;� �<a - Fee
T�HE,COMMONWEALTH OF MASSACHUSETTS Entered in computer: ,
PUBLIC HEALTH,DIVISION - TOWN OF BARNS'TAB°LE, MASSACHUSETTS Yes
ZIpplication f-r Mf!6Pfo$O1 �§p!5tem Construction Vermit
Application for a Permit to Construct O RepairX Upgrade O Abandon( )/,Complete System ❑Individual Components
Location Address or Lot No. ,? Z plCC)C r) De\\)-,,, Owner's Name,Address,and Tel.No.
Assessor'sMap/Parcel rZQ�ISW( S� j. icl 4.2
\
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
CA4Eu�►aE C,,,T, LLC S�a� ojo sl�CS-
42t3 -4 0 2-8
Type of Building:
Dwelling No.of Bedrooms 1 Lot Size �} ZS:J sq.ft. Garbage Grinder
Other Type of Building \N F_ No.of Persons Showers( K Cafeteria(
Other Fixtures L n �C._\- , 1 i CV-Q(\ ICl LC',U
Design Flow(min.required) 4rO gpd Design flow provided q�(o S gpd
Plan Date - Off- Number of sheets I t Revision Date
Title osp�\ S U
Size of Septic Tank �\c�W IS t1 C) O-\ n_Type of S.A.S.
Description of Soil
w.
Nature of Repairs or Alterations(Answer when applicable) '
Date last inspected:
Agreement: '
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board.of Health.
,���,
Sig eV^,, Date 2 . I L �J 7
Application Approved by V yl/N- Date a ( �`a-
Application Disapproved by: Date
for the following reasons 'r
- -Permit No. �(7U 7' Sy Date Issued ^�
e v(j P'v•I a I �b j r (' J)`' c THE COMMONWEALTH OF MASSACHUSETTS
�1, •r(�5/�-� BARNSTABLE, MASSACHUSETTS
c r Certificate of Complia me
THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired ( ) Upgraded (� )
Abandoned( )by ��qA"". A
at 2 2 IRt ,ra a, y, '-o,r', C)S ((, has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. Z)00-7- 00 dated
Installer C .,?,Jt 44.px z h , S LS.t Designer 151,4JA (
#bedrooms �"� U Approved-design flow a - gpd
The issuance of this permit shalll not be/construed as a guarantee that the system will function as�designed. 3
Date �/ �' /d // Inspector
--------------------------- -------------------
No. . O u—7 rDsb Fee 16
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION-BARNSTABLE, MASSACHUSETTS
Digponf i§pgtem Cou5truction Vermit
Permission is hereby granted to Construct ( ) Repair ( ) Upgrade (✓) Abandon ( ) y
System located at "Z I- lac-.,,a_, r,, thy �''SZa(�A-e
and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty
to comply with Title 5 and the following local provisions or special conditions.
Provided: Construction must be completed within three years of the date o phis pert.
Date // G 7 Approved by J�—�� �/. c C.p c
f
Town of Barnstable
FTHE tp�
do Regulatory Services
Thomas F. Geiler, Director
BARNSTABLE, !
MASS. Public Health Division
'Thomas McKean,Director
200 Main Street,Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304
Installer& Designer Certification Form
Date: 7/30/07
Designer: Shay Environmental Services, Inc. Installer: Capewide Enterprises
Address: P.O. Box 627 East Falmouth Address: P.O. Box 763
MA 02536 Marstons Mills, MA 02632
n 3/28/07 Ca ewide Enterprises was issued;a
0 Aermit to install a q U p
(date) (installer)
septic system at #22Acorn Drive, Osterville, MA based on a design drawn by
(address)
Shay Environmental Services, Inc. dated 3/06/07
(designer)
I certify that the septic system referenced above was installed substantially according to
the design, which may include minor approved changes such as lateral relocation of the
distribution.box and/or septic tank.
XX I certify that the septic system referenced above was installed with major changes (i.e.
greater than 10' lateral relocation of the SAS or any vertical relocation of any component
of the septic system) but in accordance with State & Local Regulations. Plan revision or
certified as-built by designer to follow.
OF A
r
R N
In taller s i ature) E
t NS.
� o
� .. �c�ST a
esigner's Signature) (Affix p.Here)
PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE
OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-
BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION.
THANK YOU.
Q:Health/Septic/Designer Certification Form
VENT PIPE (O Least 24 inches tall) SECTION A A
Schedule 40 PVC M/Charcoal Odor Filter
[house
10' min. from 'NOTE: ALL PIPES ARE TO BE 4' SCHEDULE 40 P.V.C. PROFILE VIEW OF LEACHING SYSTEM to septic tank EXISTING FoundationSsptk tank coven must be w�Rht�nx8''of_rGRADE m be Not t0 Scale
t rig' 8 in. of finished grade Go r
� w�
Grade over Septic Tank- ".DO Grade owr D-Box-WOO over SAS- WOO n O Y
a V ip I/l iroelMi Peeerone ;� � m�€ y� .,ram*'`
Is f 1A • rem"Cl rsMi Jesne -" ° ' � BeJlr��lf� ...�: y~y� 1�1iYiYlY•-.fL�•�"
3 HOLE 4'PVC(CAPPED)INSPECTION PORT TO BEr -
S - 0.02 INSTALLED AND TO BE VATHIN a'OF GRADE
S•0 (N-10) DIST. BOX Top Load - Etev. -96,00 `
12• Top of SAS-Elev.-95.50
EXIST. PIPE 8 NEW 1,500 GAL . 0.010" er foot A �
FROM FOUNDATION SEPTIC TANK 10' M�
n H-10 g "'� 13• Ieffeative Depth 24 EffsDfiivQ _ a f
soft eV
on
Sideluall
CONCREiE FOUNDA ° p o�i obi �300 Mte.reohti2loi ww 7ky,sai/�"► ir wwas01 ,
Ui
SYSTEM PROFILE n o 11 4 oMi LENGTHS AS SHOWN IN PLAN VIEW GENERAL NOTES
Not to Scale 0 12 a 1. Contractor is responsible for Digsafe notification, Verification of Utilities
e e 3 Effec" Wktth
L _o and protection of all underground utilities and pipes.
8 in.of 3/4"-1 1/2' a ° SD'IL ABSORPTION SYSTEM CSAS> 2. The septic tank and, distri ution box shall be set
compacted ,tone c •; level on 8 of 3/4 -1 1/2 stone.
m° 3. Backfill should be clean sand or gravel with no
w stones over 3" in size.
Bottom of Test Hole 1 Elev.-e8.00 (OR EQUIVALENT) 4. This system is subject to inspection during installation
No Groundwater Observed o 132' - NOTE: OVERALL HEIGHT OF INFILTRATOR IS 30" /EFFECTIVE HEIGHT IS 24" by Carmen E. Shay - Environmental Services, Inc.
PERCOLATION TEST 5. The contractor shall install this system in accordance
P#11547
NOTE: ALL COMPONENTS MUST HAVE RISERS TO WITHIN 6' BELOW GRADE with Title V of the Massachusetts state code, the approved plan
Date of Percolation Test: JANUARY 18, 2007 and Local Regulations.
Test Performed By. CARMEN E. SHAY, R.S. C.S.E. 6. If, during installation the contractor encounters any
Results Witnessed By. DONALD DESMARAIS ( BARNSTABLE B.O.H.) soil conditions or site conditions that are different
EXCAVATOR: Shay Environmental Services, Inc. ALL�T PIM FROM THE from those shown on the soil log or in our design
Percolation Rate: Less Than 2 MPI ® 34" �IMF«ATLtST 2 FT. 1r G« E,E��R VARIANCES REQUESTED
installation must halt & immediate notification be
.�• • ,,,., made to Carmen E. Shay - Environmental Services, Inc.
3- 5"OUTLET
Test Hole Test Hole KNOCKOUTS
- �� ';: 1. Request as Variance to install an SAS 15.5' From a Full Foundation. 7. No vehicle or heavy machinery shall drive over the
No. 1 No. 2 _ Sir ounlrr + 12' INLET a 40 mil Polyethylene Liner Has been Proposed. septic system unless noted as H-2o septic components.
e 8. Install Tuf-rite gas baffles or equals on all outlet tee ends.
DEPTH SOILS ELEV. DEPTH SOILS ELEV. __ ';� --- "
0 99.00 0 99.00 " 1ss"+ '"i » vv� 9. All Distribution Lines shall be 4 diameter Schedule 40 NSF PVC pipes.
Loamy Loamy 4' - SCH. 40 To t.75• Jr 10. All solid piping, tees & fittings shall be 4" diameter
Sand Sand PLAN SECTION CROSS-SECTION �nod'� ` n� 1 Schedule 40 NSF PVC pipes with water tight joints.
10 YR 3/2 10 YR 3/2 11. Municipal Water is Connected to ALL OF The Residence and Abutting
0'-8' A 98.33 0'-8' A 98.33 .,
Loamy Loamy
3 HOLE H-10 DISTRIBUTION BOX Properties Within 150 Feet.
Sand Sand NOT To SCALE THE PROPERTY LINES ARE APPROXIMATE AND
10 YR 5/6 10 YR 5/6 _ COMPILED FROM THE PLAN BY CHARLES SAVARY, RLS, ENTITLED
8"-34' Be 96.10 8"-34' Be 96.10 - -
SHADY NOOK SUBDIVISION IN OSTERVILE, MA
Medium Mediums
Sand Sand _ _ DATED AUGUST 10, 1964
zs Y a/a zs T a/a AND IS NOT INTENDED TO BE A SURVEY PLOT PLAN
3r-132' C, $8.00 34'-132" C, 88.00 _ IT SHOULD BE USED FOR NO PURPOSE OTHER THAN
�9 THE SEPTIC SYSTEM INSTALLATION.
EXISTING CESSPOOLS TO BE PUMPED OUT AND FILLED IN PLACE
Fit
110.00' \
NOTE: ANY STRIPPED OUT SOIL CONTAINING LEACHATE
FROM THE EXISTING CESSPOOLS TO BE DISPOSED
- _ OF AS PER SOARO OF HEALTH SPECIFICATIONS.
Qo� ffo�d �H f THERE ARE NO WETLANDS SENT IN 200' OF THE PROPERTY
Perc #1 " " LO,' $
Depth to Perc: 34 to 52 # ASSESSORS MAP 120, LOT 026
Perc Rate= Less Than 2 MPI
Groundwater Not Observed f4,6201aa1"Q Fee! +/- ( r C p�C� LEGEND
No Observed ESHWT PROJECT BENCH MARK b -
ADJUSTED H2O Elev. None TOP OF FOUNDATION ^� �,� ,2�o�
3-24•DIAM. ACCESS MANHOLES ELEV. = 100.00 (Assume ) o, �� �,� `' �"' 104X1 DENOTES PROPOSED �-
,o �• a SPOT GRADE
• ,t jr• r. CRAVIL SPACE FND. W� "'� DENOTES EXISTING
�, �•�'' , ;» �*;..s. TEST HOLE #1
( ELEV.= 99.00 X 104.46 SPOT GRADE
I_
iNIN OU cc IET ^� �-~1 4 BEDROOM o van PL PROPERTY LINE
•; Nt THE ACCESS COVERS FOR THE SEPTIC TANK. Ctj EXIST. HOUSE TEST HO 2 T° 1^^/� PROPOSED CONTOUR
{• DISTRIBUTION BOX AND LEACHING COMPONENT � �
GARAGE L
,�F�*w,: �TN. .t'7•!w-r•r�. ? SHALL BE RAISED TO WITHIN 8' OF `~ #22 ELEV 99.00 1 --- -
FINISHED GRADE. LOT #3 LOT #7 --97 EXISTING CONTOUR
STEEL REINFORCED PRECAST CONCRETE INSTALL TUF-TnE GAS BAFFLES OR EOUALS Slab Fnd
PLAN VIEW ON ALL OUTLET TEE ENDS_ r' PORCH
DEEP TEST HOLE &
3-:W REMOVABLECOS I I 4 v �< 1 2 PERCOLATION TEST LOCATION
I I ' f .s .---. 6 FOOT STOCKADE FENCE
min clearance - elsefu I I 1500 G LLON 9 -
INLET m� 2' min. Inlet to outlet e.m .+ - I 0 &-
IN Lt�T.wl OUTLET y- T I SEPTIC TANK O
t Al + n.� V-O'min. I ASPHALT i
LLquld depth I I `� P LOT P LAN
I DRIVEWAY I - ox ",.
Failed
•� :• ,.. • �• •t• •.... • ''� -Cesspool
'• • _ , zOF PROPOSED SEPTIC SYSTEM UPGRADE
11r-o• s'• a• •''
CROSS SECTION END-SECTION PREPARED FOR
z I ,
�24 ELIZABETH A. KREIG
TYPICAL 1500 GALLON SEPTIC TANK 9.9 T -fo.a' z4'--I
NOT TO SALE L = 50L 35' 1 a 58.35' ' #22 ACORN DRIVE
(H-10 LOADING)
__ ------------- - ----- ---1- --- --------------------------- --- OSTERVI LLE, MA
Design Calculations - A F
Number of Bedrooms: 4 Bedroom EXISTING A C O _ V I ff^^,,� J rr-tJ `� y ' }� PREPARED BY:
Garbage Grinder: No Uy r } �n Ali CA jR /MM�j �j �j HA TT
Leaching Capacity Required: 440 Gal./Day (MIN. PER TITLE V) (40 FOOT IGHT OF WAY) ���e 1u`` C�lY�[j,L/.�L.Li L Y L • �.J ll l
Septic Tank : - 2 x 440 Gal./Day = 880 USE EXIST. 1,000 GAL. Septic Tank. �' AY ENVIRONMENTAL SERVICES, INC.
SOtL ABSORPTION AREA: Using percolation rate of � min./inch 40 POLYETHYLENE LINER FROM ELEV. L (( ` 11 k
Bottom Area: 0.74 gal/sq. ft. x 444 sq. ft. 328.56 gallons �^• '��� 1'`� l`�� Co�neS o
96.00 to 92.25 AND TO EXTEND h �,4; � P.O. BOX 627
Sidewall Area: 0.74 gal./sq. ft. x 200 sq. ft. 148 gallons S
Providing: = 476.56 gallons 10' BEYOND SAS & FND AS SHOWN °u -� 1e S� � �r �WITAR0P`' EAST FALMOUTH, MA 02536
Use: (5) 3050 H-10 INFILTRATOR CHAMBERS, HAVING A 2' EFFECTIVE DEPTH, y TEL/FAX : 508-539-7966
TO BE USED WITH 4' OF WASHED STONE ON THE SIDES AND T�1'I�a✓ w �° °f SCALE: 1"=20' DRAWN BY: CES DATE: FEBRUARY 5, 2007
2' OF WASHED STONE ON THE ENDS.
UNITS TO BE SEPARATELY PIPED AND PLACED AS SHOWN. ���qr 1""e , PROJECT#SD1016 FILENAME: SD1014PP.DWG SHEET 1 OF 1